The Mental Health Continuum
by Deana Barakat (Fall 2016) & Kateri Donahoe (Spring 2015)
The Mental Health Continuum (MHC) is a theory that aids in defining, categorizing, and quantifying the varying levels of mental well-being and mental illness. It conceptualizes mental health not as a binary system, of being either ill or well, but rather puts mental health on a spectrum symptoms of both positive feelings (emotional well-being) and positive functioning (psychological and social well-being) (1). These feelings and behaviors place a person closer or further away from illness or well-being and allows for fluid movement through the varying stages of mental health (2). On the continuum mental health is measured based on three core components: emotional, psychological, and social well-being (3). Some researchers also incorporate measurements of the “Big Five” personality traits: extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience (1).
There are two versions of the mental health continuum, Mental Health Continuum-Long Form (MHC-LF) and Mental Health Continuum- Short Form (MHC-SF) as illustrated in Table 1 (4):
Table 1: Mental Health Continuum Theory Versions.
Version of the Theory
Scores are calculated by assigning numerical values to responses on questionnaires about topics such as, happiness and social interactions (generally rated on a 1-5 scale of frequency of certain feelings over the past month). They are then statistically analyzed and the person’s mental health score can be placed in either three or four categories. Some models only use three categories: flourishing, moderate, or languishing mental health (Figure 1) (4). Others use four categories: healthy, reacting, injured, and ill (Figure 2), which provide more detailed information about where a person lands on the continuum (2). It is worth noting that recent variations of this theory suggest that mental health and mental illness are two related, but distinct conditions of a person’s psychology, and thus should be expressed on two separate axes (Figure 3). This is based on the finding that a person may simultaneously have a severe mental illness, but copes with life well and has a positive mental well-being (Figure 3) (5). This modification, known as the Two Continua Model and has become more popular over time. The following figures illustrate the three most common variations of the Mental Health Continuum:
Figure 1. Three Category Continuum Model (Regents of the University of Michigan, Human Resources Dept., 2013).
Figure 2. Four Category Continuum Model with Actions to Take at Each Phase (Mental Health Commission of Canada, 2015).
Example: During a college semester a student can fluctuate between categorizes. At the beginning of the semester a student may be classified as Healthy, then falling into the Reacting category during midterms, and Injured during finals. However, once the semester ends that same student can fall back into the Healthy category when academic stressors are lifted.
Figure 3. Two Continua Model (Wellscotland.info, adapted from Tudor K, ‘Mental health promotion: paradigms and practice’, 1996, and Westerhof GJ, Keyes CLM, ‘Mental illness and mental health: the two continua model across the lifespan’, 2010).
Example: You may have been diagnosed with bipolar disorder, however, as you are taking the correct medications you are able to cope well life events.
Origin of the Theory:
The foremost scholar and researcher of the Mental Health Continuum is Corey L.M. Keyes. The earliest scholarly mention of the Mental Health Continuum can be found in a 2002 paper by Keyes titled “The mental health continuum: From languishing to flourishing in life”. In this paper, Keyes first introduces the categories of flourishing, moderate, and languishing mental well-being and describes the many metrics that can be quantified in order to determine a person’s level of mental well-being by way of emotional, social, and psychological factors. Keyes supports a positive, preventive approach to mental health in which we as a society abandon the notion that the absence of mental illness is a proxy for positive mental health (6).
Applications to Global Health:
The MHC-SF has been adapted in dozens of countries around the world. One notable study of the application of the theory compared findings from the Netherlands, South Africa, and Iran and examined the level of variance in the findings in order to determine cross-cultural validity. The study found that the use of emotional, social, and psychological well-being as measurements was applicable across cultures. Overall, even though they were studied under very different conditions, the MHC-SF was an effective way to assess mental health and well-being because it incorporates so many different variables that contribute to our psychological condition (8).
On the global front, it is important to note that Joshanloo and colleagues (2013) were able to validate the factor structure and full metric invariance of the MHC-SF in Iran, Netherlands, and South America (1). These findings will enable those working on global programs to better assess the mental health of individuals in the global populations. The implications of a better understanding mental well-being can potentially allow for programs to assess the proper tools for implementing public health programs and provide further knowledge of how mental health effects Daily Adjusted Life Years (DALYs).
By simplifying mental health within a certain range there is a potential to oversimplify an individual’s mental health status. As an individual’s mental health status at any given moment can vary depending biology, experiences, support, resiliency, and etc. Also, as the sample is only taken of a 30-day period, the theory may lose some of the nuances and potential changes that may occur over time that cannot be captured in one month of data. Additionally, the quantitative data about emotional, psychological, and social well-being that is gathered from the survey of the past 30 day experience is subject to recall bias. Also, the system of rating the frequency one’s own experiences on a 1-5 scale, particularly such subjective concepts as personal satisfaction and happiness, is subject to inconsistency because no two people have the same concept of emotional or social satisfaction. Although simplified the varying levels, categories, and metrics, it can be difficult for someone outside the profession to understand the theory and its applications as well. Lastly, the MHC-SF has only been validated for individuals 12 and older, limiting the population size that can use the form (6).
(1) Joshanloo M, Nostrabadi M. Levels of mental health continuum and personality traits. Soc Indic Res 2009; 90: 211-224. doi:10.1007/s11205-008-9253-4.
(2) Mental Health Commission of Canada. The working mind: workplace mental health and wellness summary [Internet]. 2015 [cited 2015 March 15]. Available from:http://www.mentalhealthcommission.ca/English/initiatives-and-projects/working-mind.
(3) Westerhof GJ, Keyes CLM. Mental illness and mental health: the two continua model across the lifespan. J Adult Dev 2010 Jun; 17(2): 110–119.
(4) Keyes, CLM. Brief description of the mental health continuum short form (MHC-SF) [Internet]. Atlanta: Emory University; 2009 [cited 15 March 2015]. Available from:http://calmhsa.org/wp-content/uploads/2013/06/MHC-SFEnglish.pdf
(5) Lamers, SMA. Positive mental health: measurement, relevance and implications [Internet]. Enschede, the Netherlands: University of Twente; 2012. Chapter 2, Evaluating the psychometric properties of the Mental Health Continuum-Short Form (MHC-SF). [cited 15 March 2015]. Available from: http://www.academia.edu/2891130/Evaluating_the_psychometric_properties_of_the_mental_health_Continuum_Short_Form_MHC_SF_.
(6) The Mental Health Continuum Short Form [Internet]. Association of American Colleges & Universities. 2011 [cited 2016 Oct 26]. Available from: https://www.aacu.org/node/5683.
Short Form Version of Mental Health Continuum
Long Form Version of Mental Health Continuum